Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus

Marcello Casaccia Bertoluci, João Eduardo Nunes Salles, José Silva-Nunes, Hermelinda Cordeiro Pedrosa, Rodrigo Oliveira Moreira, Rui Manuel Calado Da Silva Duarte, Davide Mauricio Da Costa Carvalho, Fábio Rogério Trujilho, João Filipe Cancela Dos Santos Raposo, Erika Bezerra Parente, Fernando Valente, Fábio Ferreira De Moura, Alexandre Hohl, Miguel Melo, Francisco Garcia Pestana Araujo, Rosa Maria Monteiro Castro De Araújo Principe, Rosane Kupfer, Adriana Costa E Forti, Cynthia Melissa Valerio, Hélder José FerreiraJoão Manuel Sequeira Duarte, José Francisco Kerr Saraiva, Melanie Rodacki, Maria Helane Costa Gurgel Castelo, Mariana Pereira Monteiro, Patrícia Quadros Branco, Pedro Manuel Patricio De Matos, Pedro Carneiro De Melo Pereira De Magalhães, Roberto Tadeu Barcellos Betti, Rosângela Roginski Réa, Thaisa Dourado Guedes Trujilho, Lana Catani Ferreira Pinto, Cristiane Bauermann Leitão

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Background: In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. Methods: MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. Results and conclusions: In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.

Original languageEnglish
Article number45
JournalDiabetology and Metabolic Syndrome
Issue number1
Publication statusPublished - 24 May 2020


  • Atherosclerotic disease
  • Cardiovascular risk
  • Chronic kidney disease
  • Diabetes treatment
  • Guidelines
  • Heart failure
  • Ischemic heart disease
  • Type 2 diabetes


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